School of Nursing, Ateneo de Davao University

Delivery Room
Procedures
Manual of Nursing 2011 Edition

(Revised: 2014, 2022)

 Manual of Nursing Procedures (AdDU)

PROCEDURE: ADMISSION TO THE LABOR ROOM

Definition
Labor and delivery are combination of processes by which the fetus, the placenta and the
membranes are separated and expelled from the body of the pregnant woman after a period of
approximately 280 days or 40 weeks gestation.

Equipment

· Sterile gloves
· Stethoscope/fetoscope
· Sphygmomanometer
· Thermometer
· Clock/wristwatch with second hand

PROCEDURE RATIONALE

1. Greet the patient with cordiality, Calling the patient by name, extending
friendliness, and reassurance. Introduce common courtesies, and welcoming the
yourself to the patient and the patient to patient and relatives often help them to feel at
her roommates. ease and less frightened.

2. Check consent for confinement and prepare These actions help to avoid legal suits.
patient physically by assisting her in
changing into a clean gown.

Losing items is upsetting to the patient and

3. Endorse valuables like jewelry, prosthesis,
and clothes to relatives. It is important to
receive from significant others the required
*OB kit, baby’s layette and diaper and
ascertain if it is complete
4. Orient patient to the set-up, personnel and
hospital rules.
can result in legal problems. The hospital
agency requires each patient on labor to bring
baby’s layette and supplies necessary for
delivery.
The information is an important part of
permanent record and is used to begin the
patient’s care.

Performing Labor Watch ensures assessment

5. Initially, ascertain the status of both mother of accurate general condition of the mother
and baby by performing LABOR WATCH and her progress in labor as well as the
and/or Partograph such as listening to condition of the baby.
the fetal heart tones and assessing
maternal vital signs and character of uterine
contractions (Frequency, Interval, Duration,
Intensity)
Optional: Patient is being hooked to EFM
(External Electronic Fetal Monitor)

6. Stay with patient during labor pains. Teach Patient and relatives have worries and fears
pursed-lip breathing techniques. too and usually feel better when they are
accompanied by one of the members of the
Optional: Presence of a watcher of health team.
choice by the patient during labor such
as husband/mother in institutions where Explaining the agency routines and how to use
it is allowed. equipment helps to relax the patient. Knowing
how to use equipment help to prevent
7. Document pertinent observations. accidents.
*OB KIT – In Davao Regional Hospital (DRH), this is kit purchased at the time of admission, which includes
the following (1) Adult Diaper (1) Baby Diaper, plastic cord clamp, bonette (2) sunction catheter for baby,
(2) pairs of sterile gloves, (1) ampule of oxytocin, (1) ampule of methergin, (2) Lidocaine, (1) 5cc syringe,
(1) 3cc syringe), (1) chronic suture.
NO OB KIT - In Southern Philippines Medical Center, OB kits are not required. However, often the
procurement of the needs of the patient shall be done by the watcher upon the call of the nurse in the
watcher’s room. Most of the materials and equipment needed are provided by the hospital

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THE LEOPOLD’S MANEUVER AND TAKING THE FETAL HEART TONE

Definition
Leopold’s maneuver is a systematic abdominal palpation to determine the position and
presentation of the fetus. It is done at about 32 weeks age of gestation and above.

Purpose
• To identify fetal presentation, the presenting part lie, attitude and degree of descent.
• To estimate the size and number of fetus.

Definition
The fetal heart tone (FHT) is the heart beat of the fetus that ranges from 120-160 beats per
minute. Taking the FHT, its rate and characteristics, is one way of assessing the status of the
fetus

Purpose:
• To monitor the progress of a woman’s contraction pattern.
• To monitor the condition of the fetus in response to the stress of uterine contractions.

Equipment:
• Stethoscope

PROCEDURE RATIONALE

1. Explain to the patient the purpose of the The patient will feel reassured if the
procedure. procedure is explained and if she is handled
gently and considerately.

2. Instruct the patient to void. A full bladder will prevent discomfort during
palpation and will make her pelvis and
uterus more accessible for palpation.

3. Ascertain the presentation and position of

the fetus by (performing the 4 steps of the
Leopold’s maneuver) palpating the
abdomen of the mother.

4. Leopold’s maneuver: Proper positioning relaxes both the mother

Position the client in dorsal recumbent. and the baby. It also facilitates the easy
location, presentation and lie of the fetus.

5. Drape the client and expose the abdomen To provide privacy and promote good
from the level of the xyphoid process down thermoregulation.
to the symphysis pubis.

6. Perform the four maneuvers. During the The position favors accurate performance of
first three maneuvers, stand at the side or the maneuvers.
at the foot part of the client’s bed and face
the head part.

7. Warm two hands by rubbing one against The use of warm hands during the palpation
the other before placing them on the prevents tension and contraction of the
abdomen. abdominal muscles.

8. FIRST MANEUVER: To determine the fetal part lying in the

With both hands, palpate upper abdomen fundus, whether breech or
and fundus to: cephalic.
Determine the presentation
Consistency: Head is round, hard,
Breech-soft and irregular at the fundal area
Mobility: Head moves independently
Breech-less mobile

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PROCEDURE RATIONALE

9 SECOND MANEUVER:
With both hands moving down; Palpate the To determine the fetal back for fetal heart
sides of the uterus from the top to bottom. tone, usually found in the left lower
While moving the right hand, keep the left quadrant.
hand steady on the other side of the
abdomen. While moving the left hand, keep
the right hand steady on the other side of
the abdomen.
One side-smooth, hard, resistant surface:
FETAL BACK: SITE FOR
AUSCULTATING THE FHT
Other side: angular modulation (knees and
elbows)

10. To obtain the BASELINE fetal heart rate,

it must be taken between contractions.
(relaxed uterus) Place the bell of the
stethoscope over the quadrant of the
mother’s abdomen where the fetal back is
located:
Right occipito-anterior: RLQ
Left occipito-anterior: LLQ
Left occipito-posterior: LEFT PELVIC SIDE
Right occipito-posterior: RIGHT PELVI SIDE

11. Listen for and count the fetal heart tone in One full minute is the ideal time in
one full minute. FHR: 120-160 bpm assessing the FHR accurately and to allow
for variations.

12.Take note of the rate, regularity, strengths
and any deviation of the FHT. Any
abnormality should be reported promptly.
13. Record the characteristics of the fetal heart
tone and note the position on the abdomen
where the fetal heart tone was located.
Reporting any abnormality promptly delivers
prompt treatment. Correct and complete
data collection can contribute to continuous
care and data collection for quality nursing
care.

14.THIRD MANEUVER: To determine engagement of the presenting

With the right hand over the symphysis, part and its mobility.
identify the presenting part by grasping the
lower abdomen with thumb and fingers.
(Pawlick’s grip)
Assess whether the presenting part is
engaged in the pelvis. (If the head is
engaged, it will not move. If it soft it is the
back. This will confirm
the findings during the first maneuver.

15. FOURTH MANEUVER

Face the foot part of the patient’s bed,
To determine the fetal attitude and degree
stand on either side of the patient’s bed.
of fetal extension or flexion into the pelvis;
With both hands, assess the descent of the
it should be done only when the fetus is in
presenting part by locating the cephalic
cephalic presentation.
prominence of the brow:
Place your fingers on both sides of the
uterus, about two inches above the inguinal
ligament. Press downwards and inwards.
If the palm during palpation meets no
obstruction it means that the fetal back is
palpated. If the other hand will meet and
there is and obstruction, the fetal brow is
palpated.

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16. Reposition the client comfortably and To convey concern and to promote
assist in redressing with her clothes. comfort.

Correct and complete data collection can

17. Document findings. contribute to continuous care and data
collection for quality nursing care.

ILLUSTRATION OF THE LEOPOLD’S MANEUVER

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EINC CHECKLIST FOR RETURN DEMONSTRATION:

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UNCOMPLICATED ACTUAL NORMAL SPONTANEOUS VAGINAL DELIVERY BY

HANDLE, ASSIST AND CORD CARE NURSE (HOSPITAL SETTING) With
Integration of Essential Newborn Care (ENC)
FOR SIMULATION
Purpose:
• To facilitate a successful delivery with least discomfort on the part of the mother.
• To safeguard mother and baby against infection.
• To prevent hemorrhage.

Equipment:
-Sterile gown and gloves (optional in the Philippine Setting)
-a Sterile Primi set containing the following instruments and materials placed on the
DR Table:
1. 1 plastic cord clamp/clip (for cord dressing)
2. 1 Mayo scissors
3. 1 big artery clamp/ 1 big forcep
4. Sterile gauze (at least 5 pieces, set aside 1 piece for cord dressing)
5. Sterile gloves
6. 1 Needle holder
7. Sterile syringe with needle (5 cc)
8. 2% of Lidocaine
9. Chromic 2-0 (double needle: round and cutting)
10. 1 tissue forceps
- a Sterile Multipara set: same with primi but without #6-10 materials above
-Pail/ basin
-Urethral straight catheter
-Perineal Flushing set
-Clean Cloth/ baby’s linen/receiving blanket
-Identification band

Patient position:
Lithotomy position

PROCEDURE RATIONALE

1. Gather the necessary equipment. Preparing the equipment saves time and
Prepare the birthing instrument set effort and for assuring the correct and
per hospital protocol. Place yellow plastic completeness of equipment needed.
waste on the DR table (specifically where
the buttocks of the patient is); Prepare
Primi/Multipara Set on the Mayo tray.
-Check room temperature of DR, must be
at 25-28°C and free of airdraft.
- Notify appropriate staff.
- Check resuscitation equipment.
Lithotomy position is a common position of
2. Assist the client in lithotomy position childbirth. Perineal
Lithotomy position prep
is a is
common
best done
position
through
of
and the ASSISTING NURSE performs perineal flushing
childbirth. Perineal prep is best done through
perineal flushing. perineal flushing
Handwashing is the single and most effective
3. Wash hands with clean water and way
Handwashing
in deterring
is the singlethe
and most
spread
effective
of
soap, or scrub hands for at least 40-60 microorganisms.
way in deterring the spread of
secs microorganisms.
(according to WHO 1- 2- 3- 4-5) To prevent cross- contamination and assure
asepsis

4. The HANDLE NURSE and the CORD

To prevent cross- contamination and assure
CARE NURSE don gown (per protocol) 198 asepsis
and sterile gloves. Double-gloving per
hospital policy. The HANDLE NURSE
This prevents injury/laceration while the
arranges the sterile set in Mayo tray in a
perineum
 Oxytocin
is stretching
preparation
and to prior
prevent
to the
sudden
Manual of Nursing Procedures (AdDU)
PROCEDURE
5. When the perineum bulges, the
HANDLE NURSE protects it with an
operating sponge and applies moderate
pressure at the perineum and on the
fetal head. (Ritgen’s maneuver)
6. Coach the patient to bear down when
there are contractions until the head is
out, when contraction stops, instruct the
patient to catch up breathe by opening
and breathing through the nose.
7. The HANDLE NURSE places the 1st dry
sterile linen on top of the abdomen of
the mother.
8.Watch for cord coil around the neck of
baby. If present, insert finger to ease
pressure, skip coil down baby’s shoulder
9.Wait for external rotation. The HANDLE
NURSE eases the expulsion of the head
by slowly pulling head up and down by
interlocking neck/mandible area of the
baby in between index and middle fingers
of both hands until the anterior shoulder
comes out, then the posterior shoulder
next and the rest of the body.
10. The CORD CARE NURSE calls out and
note for the time of delivery and sex of
the baby. A child is considered born,
when the whole body is delivered. “Baby
(Girl/Boy) out! (time)!”
FOUR CORE STEPS OF ESSENTIAL
NEWBORN CARE
I. Within first 30 seconds: Immediate
Thorough Drying
11. Place the newborn on top of the
mother’s abdomen. The ASSISTING
NURSE dries newborn using 1st dry linen /
cloth thoroughly for at least 30 sec. Wipe
eyes, face, head, front, back & arms, legs..
-Remove wet cloth. Replace with a new one
-Do a rapid assessment of the baby noting
the breathing (baby’s cry) while drying.
Note during the 1st sec.
- Do not ventilate unless baby is
floppy / limp & not breathing
- Do not suction unless mouth / nose
are blocked with secretions
- Do not wipe off vernix
- Do not bath newborn
- No slapping
- No hanging upside down
- No squeezing of chest
RATIONALE
This prevents injury/laceration while the
perineum is stretching and to prevent
sudden expulsion.
Bearing down is effective when there is
contraction
The first sterile and dry linen is used for
drying the baby. Preparing this ahead will
help ease the drying of the baby.
To prevent compression of the cord.
To prevent compression of the cord.
Forcing the delivery of the baby may cause
the laceration of the cervix or the vaginal
wall.
It is important to loudly tell the time of birth
- this helps in accurate recording of the
time and more importantly, alerts other
personnel in case any help is needed
During the first 30 seconds of birth,
thermoregulation in a newborn is easily
disturbed because their neurological
systems are not fully developed at birth.
Certain characteristics such as low
subcutaneous fat, exposure of baby to cold
and low birth weight increase the risk of
hypothermia.
Washing or bathing the baby may also lead
to infection and hypothermia.
At the time of drying itself, the baby's
breathing should be assessed. A normal
newborn should be crying vigorously or
breathing regularly at a rate of 40-60
breaths per minute. If the baby is not
breathing well, then the steps of
resuscitation have to be carried out.
If after 30 seconds of thorough drying
newborn is not breathing or is gasping the
199 following actions are recommended:
a. Reposition, suction and ventilate
b. Clamp and cut the cord immediately
 Manual of Nursing Procedures (AdDU)

PROCEDURE RATIONALE

II. After 30 seconds of drying: Early Skin-
to-Skin Contact (SSC)
12. If newborn is breathing or crying, the
ASSISTING NURSE:
a. Positions the newborn prone on the
mother’s abdomen or chest (between the
breasts) with head on the side
Early skin-to-skin contact promotes more
stable and normal skin temperatures, more
stable and normal heart rates and blood
pressures, higher blood sugars. They are
more likely to breastfeed exclusively longer.
It allows the “good bacteria” from the
mother’s skin to colonize the newborn.

b. Instructs the mother to hold the baby It also allows the mother to bond, and to
(“Kangaroo care”) while assuring safety by promote uterine involution/contraction
supporting the baby’s back.
c. Covers the newborn back with baby’s linen
or blanket
d. Covers the newborn head with a bonnet
e. Place identification bond on ankle (not This helps in easy identification of the baby,
wrist) avoiding any confusion.
Note:
- If the baby is crying and breathing
normally, avoid any manipulation by
routine suctioning that may cause
trauma or suctioning infection
- SSC is performed / doable also for
Cesarean Section newborn
- Do not separate the newborn from the
mother as long as the newborn does
not exhibit severe chest in-drawing,
gasping or apnea, and the mother does
not need urgent medical stabilization.
- Do not put the newborn or cold/wet
surface.
- Do not wipe off vermix if present.
- Do not bath newborn earlier than 6
hours of life.
- Do not do foot printing.

13. When the handle nurse palpates the
abdomen and ensures that there is no second
baby, and 1 minute after baby’s birth, the
ASSISTING NURSE administers Oxytocin 10
units (1mL) IM at the deltoid of the patient
(mother).
Oxytocin administration is the 1st step in the
AMTSL to reduce postpartum blood loss,
and to enhance detachment of the placenta
to the lining of the uterus.

III. 1-3 minutes: Properly-timed Cord

Clamping

14. Meanwhile, the CORD CARE NURSE
wearing sterile gloves waits until cord
pulsation stops or withing 1-3 minutes
after birth while also noting the APGAR
Scoring.
a. Clamp the cord with the sterile plastic cord
clamp/cord clip (1st clamp), 1 inch (2 cm)
above the umbilical base.
b. Milk the cord or strip the cord of blood
away from the newborn once, and then200
apply the 2nd clamp at least 5 cm from the
base using a forceps.
Delaying cord clamping 1-3 minutes after
birth or waiting until the umbilical cord has
stopped pulsating has been shown to
increase newborn’s iron reserves. It also
reduces the risk of iron-deficiency anemia,
improves blood circulation, and prevents
hemorrhage.
APGAR Score describes the newborn health
condition after birth
 Manual of Nursing Procedures (AdDU)

PROCEDURE RATIONALE

Note: The HANDLE NURSE holds the

forceps (2nd clamp) waiting for the placenta
to be delivered.

15. The HANDLE NURSE places a sterile lining
over the mother’s abdomen and delivers the
placenta by controlled cord traction and
countertraction of the uterus within 20 mins.
After 20 minutes if the placenta is difficult to
deliver, refer to the physician or midwife.
16. After the placenta is out, the HANDLE
NURSE massages the uterine fundus firmly and
gently.
A sterile lining ensures maintenance of
sterility of the handle nurse, while doing the
controlled cord traction down the placenta
and countertraction on the uterine fundus.
This is the 2nd step in the AMTSL that helps
reduce postpartum hemorrhage and uterine
prolapse.
Uterine massage promotes uterine
contraction from the established Oxytocin
administration and reduces the incidence of
postpartum hemorrhage.

IV. Within 90 minutes (1 ½ hour) after

birth – Non-separation of Newborn from
Mother for Early Breastfeeding
Breastfeeding within the first hour of life
17. Meanwhile, after ensuring that the cord is prevents neonatal deaths. Delaying the start
properly clamped and cut, the CORD CARE of breastfeeding makes the newborn prone
NURSE replaces the ASSISTING NURSE to infection.
in supporting the newborn’s back. Ascertain
non- separation of newborn from the
mother for early breastfeeding or “latching
on”.

The CORD CARE NURSE educates the

mother about breastfeeding.

Note:
- leave newborn on SSC to mother’s
chest/abdomen
- observe for feeding cues: licking,
rooting
- encourage mother to nudge newborn
towards the breast
- counsel on proper positioning &
attachment
- minimize handling by health workers
- Do not give sugar water, formula or
other prelacteals
- Do not give bottles or pacifiers
- Do not throw away colostrums
- Postpone washing until at least 6 hours
- Postpone bathing of baby until at least
6 hours after birth.

18. Meanwhile, the HANDLE NURSE inspects Retained placental fragments may cause
the placenta for completeness of cotyledons. bleeding.
Gently place the placenta in the placental
pail/basin. The gloved hands and the Receive it with the non-dominant hand,
clamp/forceps must not come in contact with maintaining sterility.
any part of the container. Once the placenta is
secured in the container, remove the clamp Retained placental fragments may cause
attached to the distal end of the cord, and place bleeding.
201
where appropriate or in a leak-proof container.
 NOTE: For Muslim clients, the placenta
is to be handed over to the patient or
 Manual of Nursing Procedures (AdDU)
PROCEDURE
19. The ASSISTING NURSE shall take the
patient’s blood pressure immediately after
the delivery of the placenta, and inform the
handle nurse/doctor/midwife.
20. Using sterile gauze, the HANDLE NURSE
inspects the vagina and the perineum.
21. If there is no laceration, proceed with the
immediate post-partum care. If there is a
laceration (2nd-4th degree), and episiotomy,
the HANDLE NURSE prepares in assisting
for an episiorrhaphy by the physician.
22. After episiorrhaphy, perform perineal care.
23. Dry the perineal area and the buttocks.
Apply a perineal pad. The perineal pad
should be checked if soaked, every 15
minutes for the first hour postpartum
24. The HANDLE NURSE washes and dries all
instruments from the decontaminated
solution with antiseptic soap and water.
Used sutures and sharp needles are
disposed properly in sharps container.
25. The ASSIST NURSE continues to monitor
the mother and the baby dyad every 15 mins
for the first hour, and 30 mins after second
hour, 1 hour thereafter.
 NOTE: Refer any unusuality in the vital
signs.
26. Remove gloves and dispose properly.
Perform proper handwashing
27. Document.
202
RATIONALE
The placental delivery poses risk for
bleeding and hemorrhage. Taking the vital
signs, esp. BP q 5 mins for first 15 mins will
ensure assessment of hemodynamic stability
of the client.
Inspection can help in identifying any
laceration or bleeding.
The physician only performs the
episiorrhaphy under any circumstances. The
nurse ascertains the need of the physician
during the procedure.
To cleanse and to reduce the risk of
infection on the perineal area.
To disinfect and reduce the risk of cross-
infection/contamination
To disinfect and reduce the risk of cross-
infection/contamination.
Monitoring stability of the vital signs helps in
ensuring that the mother and baby dyad is
safe and if complications arise, this can be
referred immediately.
Proper nursing after care must be observed
for safety against communicable disease
spread through blood and secretions, and to
deter spread of microorganisms.
Nursing documentation is a principle that
allows all interventions are properly planned
and delivered to the client legally.
 Manual of Nursing Procedures (AdDU)

NON-TIME BOUND AND NON-IMMEDIATE CARE OF THE NEWBORN

Purpose

• To safeguard against infection

• To assess for abnormalities

Equipment

• 1 Vitamin K ampule (0.1cc)

• 1 Hepatitis B vaccine (0.5cc)
• 1 cc syringe with needle # 2pcs
• 3cc syringe with needle # 1pc
• digital thermometer
• Terramycin ointment
• Weighing scale
• Cotton balls: separate container with alcohol and with sterile water
• 70% Alcohol (optional)
• Tape measure
• Baby’s Layette: baby’s shirt, bonnet, mittens, booties, diaper, baby’s blanket
• Gloves (working)

PROCEDURE RATIONALE

After the Four Core Essential Steps of Newborn

Care: and while the baby is still on the top the
mother’s abdomen/chest; (Gloves are don for
working.)

1.After 90 mins or when FULL BREASTFEEDING The cord care nurse informs the mother of
is done, the CORD CARE NURSE prepares the the next procedure, ensuring trust and
mother and the baby for the anthropometric cooperation.
measurements and injection.

-Use the sterile gloves worn earlier as a clean

working gloves in the preparation of the
materials in injection.

2. The CORD CARE NURSE identifies and This is to ensure the neonate’s identity and
checks the accuracy of the neonate’s avoid identity errors.
identification band.

3. The CORD CARE NURSE, informs the To provide a basis for future evaluation, and
mother of the condition of the baby, and that to determine the neonate’s progress, and
you are going to: note for anomalies.

A. Weigh the baby in the weighing scale Baseline assessment of the baby is essential
(in kg) and record. Notify the for knowing the appropriation of the age of
pediatrician promptly. gestation and overall health condition.

B. Place the baby back to the mother’s Keeps the baby warm by preventing heat loss
abdomen and skin to skin. Assess the
baby (anthropometric measurement of
the head, chest, abdomen, and length)
Measure anthropometrics such as:
• Length: 47.5-53.75 cm
• Head circumference:33-35 cm
• Chest circumference- 31-33 cm
• Abdominal circumference: 31-33 cm203
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PROCEDURE
4. Administer the following as prescribed:
A. Apply Crede’s prophylaxis- ophthalmic
ointment as prescribed, over the lids of both
eyes. Starting from the inner canthus to outer
canthus of the eye making sure that the tip of
the ointment tube will not come in contact with
the baby’s mucous membrane. Then,
manipulate eyelids to spread medication in the
eyes.
B. Inject Vit. K 1mg or 0.1cc intramuscularly
at Left Vastus Lateralis
C. Inject Hepa B vaccine (0.5cc) IM
opposite to the site where Vit K is given- Right
Vastus Lateralis.(optional per hospital protocol).
D. Inject Bacillus Calmette Guerin (BCG)
Vaccine 0.1 cc intradermally at Upper Arm
5. Check the initial temperature of the baby
rectally by inserting a rectal thermometer inside
the anus at 1 to 1 ½ inches. Note for any
congenital anomaly like imperforated anus.
6. Ensure the baby’s bonnet and ID tag are still
intact. Put a diaper on the baby. Securing the
diaper tapes on the side while allowing the cord
clamp exposed out and on-air dry. Inform the
mother not to place “Bigkis” or abdominal
binder.
7. Inform the mother to maintain 90 minutes of
skin-to-skin and non –separation to the baby
(prone to the mother).
- Encourage breastfeeding by demand.
- Delaying of bathing 24 hrs after birth.
- Do other health teaching whenever
necessary like postpartum family
planning, newborn care, etc.
8.Remove gloves and dispose properly. Do after
care and perform proper handwashing
9.Document. Record all pertinent information in
mother-baby dyad monitoring, the
anthropometric measurements, and the
injections given.
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RATIONALE
It is part of the routine care of the newborn to
give prophylactic eye treatment against
gonorrhea conjunctivitis or opthalmic
neonatorum. Neisseria gonorrhea, the causative
agent, may be passed on the fetus from the
vaginal canal during delivery. This practice was
introduced by Crede, a German gynecologist
in1884. Silver nitrate, erythromycin and
tetracycline ophthalmic ointments are the drugs
used for this purpose.
The newborn has a sterile intestine at birth,
hence, the newborn does not possess the
intestinal bacteria that manufactures vitamin K
which is necessary for the formation of clotting
factors. Vit K is given as prophylaxis against
bleeding. Thereby, it also helps in the
production of the GI normal flora.
First dose of Hepa B vaccine is given to the
baby for active immunity against Hepatitis B.
BCG helps in the active immunity against
tuberculosis (TB.)
Initial temperature allows for checking of an
imperforated anus, a congenital anomaly
which the opening to the anus is missing or
blocked.
Wearing of the diaper of the baby keeps
him/her dry and comfortable. Placing the
cord out on air-dry will facilitate necrosis
from the maternal flora during skin-to-skin
and hasten the fall-off of the umbilical cord.
Proper health education to the mother helps in
assuring her responsibility as a mother and
ensuring that patient’s physiologic and learning
needs are provided in the nursing care.
Proper nursing after care must be observed for
safety against communicable disease spread
through blood and secretions, and to deter
spread of microorganisms.
Nursing documentation is a principle that allows
all interventions are properly planned and
delivered to the client legally.
 Manual of Nursing Procedures (AdDU)

BATHING OF THE NEONATE (24 HOURS AFTER BIRTH)

Newborns are uniquely susceptible to hypothermia because they have a large body surface
area, which helps heat loss; they lack insulation; and lack the body mass to produce and save heat.
They are also dependent on caregivers to keep them warm and dry. Care of the newborn at
childbirth includes keeping it warm by drying immediately after birth and delaying a bath until the
temperature is stabilized. The periods of delay in bathing vary from 6 hours to overnight to 24 hours
and even longer.

Materials:

Basin with clean, lukewarm water

Baby’s soap
Baby’s Layette: dress, mittens, socks bonnet
Baby’s diaper
Soft cloth/ baby’s linen

PROCEDURE RATIONALE

1. Wash hands.

2. Explain the procedure to the mother.
3. Prepare the materials. Check the room
temperature if it is warm and air- draft-free.
Ensure that the water is lukewarm by
checking with the elbow or dorsal side of
the palm.
Enhances cooperation and eases away
confusion and doubts to the mother
Saves time, energy and effort. Checking the
room temperature and water to be warm
maintains stable temperature of the baby
and prevents hypothermia and scalding.

4. Undress the baby. To make ready for the bath.

5. Bathe the neonate. To promote cleanliness and comfort

a. Place the head of the baby on your non- Prevents cradle cap from forming especially
dominant palm and support the body with over the frontal area;
the forearm (football hold position)
b. Close ears by folding the ears inward To secure the baby’s head and prevent water
using the thumb and the middle finger of from entering the baby’s ears
the non-dominant hand.
It prevents entry of debris and
c. Wipe the eyes from inner to outer microorganisms into the lacrimal gland.
canthus with wet cotton swabs, or non-
woven cotton sponges. Wipe also the
forehead, cheeks, and chin (from least
contaminated to most contaminated)

d. Tilt the head back, wet the hair and apply To minimize cold exposure and prevent
mild baby soap or shampoo. Gently wash hypothermia.
the scalp. Rinse with water and dry hair
with towel.

e. Place the baby into the tub with shoulders To prepare in washing the trunk.
neck and head supported by the
nondominant hand and the trunk and legs
in water. To maintain normal body temperature and
prevent unnecessary heat loss.
f. Wet the baby’s neck,
chest,hands,abdomen, legs and To expose the neck folds for a more
perineum. thorough cleansing

g. For cleaning back and buttocks transfer

the baby to the other hand in such a way
that neck and chest are supported over
the palm, by holding the baby securely

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h. Apply soap concentrating on skinfolds and

rinse with the water. Help prevents skin irriration.

4. Pat the baby dry with a soft cloth and For better convenience.
wrap the body by spreading a clean and
dry towel over a flat surface.

5. Care of the cord: (according to ENC)

a. Wash hands Recent studies have shown that applying

b. Put nothing on the stump. alcohol to the cord is not necessary and
c. Fold diaper below stump. Keep cord doing so may actually increase the amount of
stump loosely covered with clean clothes. healing time.
d. If stump is soiled, wash it with clean
water and soap. Dry it thoroughly with
clean cloth.
e. Explain to the mother that she should
seek care if the umbilicus is red or
draining pus.
f. Teach the mother to treat local umbilical
infection if present three times a day.
- Wash hands with clean water and
soap.
- Gently wash off pus and crusts with
boiled and cooled water and soap.
- Dry the area with clean cloth.
- Paint with gentian violet.
- Wash hands.
- If pus or redness worsens or does not
improve in 2 days, refer urgently.
g. Leave cord exposed to air. Do not apply The cord dries and separates more rapidly if
dressing or abdominal binder over it. it is exposed to air.
h. Instruct the mother to report any
unusual signs and symptoms which
infection.
-Foul odor in the cord
-Presence of discharge
-Redness around the cord
-The cord remains wet and does not
fall off within 7 to 10 days
- Newborn fever

6. Dress the baby and keep warm. May use Maintains stable body temperature.
swaddling technique but not too tight. Swaddling helps the baby sleep longer with
fever awakenings.

7. Reinforce breastfeeding techniques and

allow time for mother and child bonding.

8. Document the procedure.

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PERINEAL CARE

Definition: It is the washing of the genitals and anal area with plain water or medicated solutions

Purposes:
1 .to cleanse the area of secretions and excretions.
2. to reduce unpleasant odors
3. to prevent skin irritations and excoriation.
4. to control the potential for infection.
5. to promote comfort.

Equipment:
- bath blanket
- bath towel
- flushing can with sterile water
- cotton balls in soap sud solutions
- cotton balls in antiseptic solutions ( preparation for catheterization)
- dry cotton balls
- Bedpan
- rubber sheet
- pick-up forcepts in disinfectant solution
- working forcepts in disinfectant solution
- waste receptacle
- clean underwear/ diaper
- toilet paper ( optional )
- paper lining ( newspaper )
- working gloves

PROCEDURE RATIONALE

1. Identify the patient and explain the Patient identification validates the correct patient
procedure correctly and clearly to the and correct procedure. Discussion and
patient. explanation help allay anxiety and prepare the
patient for what to expect

2. Wash hands Prevents the spread of microorganisms

3. Gathers all needed materials and pieces of
equipment at bedside.
Bringing everything to the bedside conserves
time and energy. Arranging items nearby is
convenient, saves time and avoids unnecessary
stretching and twisting of muscles on the part of
the nurse.

4. Provide privacy by closing door and pulling Provides privacy

curtains

5. Change the top sheet with the bath blanket. Maintains warmth of the patient.
And is respectful with the patient’s modesty.
6. Place the rubber sheet, and line it with a
bath towel under the patient's hips. Protects bed linens.

7. Fold patient's gown towards hypogastric

area. Don working gloves. Remove the
underwear or diaper.

8. Position client in dorsal recumbent position. Promotes clients comfort.

Drape the patient. Place bedpan on the client Minimum exposure lessens embarrassment and
perineal area. helps to provide warmth

9. Flush the perineal area with warm water Secretions that tend to collect around the labia
minora facilitate bacterial growth.

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RATIONALE
PROCEDURE
Using different cotton balls prevents the
10. Cleanse the area with cotton balls in soap
suds solutionin the following order;
transmission of microorganisms from one area to
the other. Wipe from the area of least
1- mons veneris
contamination to that of greatest
2 - far labia majora then thigh
3 - near labia majora then thigh
4- far labia minora
5 - near labia minora
6- from symphysis pubis to vaginal orifice
7- from symphysis pubis to anus

11. Rinse the area well with warm water.

Note: The preparation of catherization
Cleanse the area with cotton balls in betadine
solution in same order as no. 10. then proceed
to catheterization

12. Dry the area with dry cotton balls in the

same manner.

13. Perform treatment if indicated.

Residual moisture provides an ideal environment
14. Remove bedpan and place it under the bed
for the growth of microorganisms
with paper lining. Remove the bath towel
and rubber sheet.

15. Replace the bath blanket with the clean top

sheet.
Promotes client’s comfort
16. Pull down the patient's gown and put on
the clean under-wear or diaper.

17. Make the patient comfortable

Promotes proper disposal of contaminated
18. Do the after care. Bring all equipment to
materials thus deter the spread of
the utility room.
microorganisms and prepare the equipment for
the next user.

19. Remove gloves and wash hands

Documentation promotes continuity of care and
20. Document the performance of the
communication.
procedure, the objective and subjective
findings and the patient's response.

image source: http://www.designingvagina.com/vaginal-procedures/perineoplasty/)

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